larger nerve cup

Discussion in 'Optometry Archives' started by Henry, Oct 21, 2003.

  1. Henry

    Henry Guest

    Hi group,

    I am 37 years old and since the first time I visited my opthamologist
    I was told that my nerve cup is a bit larger than most people. I was
    told to return every year to check eye pressure and visual field so as
    to make sure it is not glaucoma that is developing. And thank Heaven
    every thing seems to remain normal in the last ten years. Last week my
    6 year old son were told by a optometrist that his nerve is big, and
    he has to return every year to check eye pressure... etc. Seems like
    he inherited the same problem from me.

    My question to the group is:

    1. Do all 'larger nerve cups' develop into glaucoma eventually ?

    2. If my eye pressure is normal and my visual fields do not change
    over time
    does that mean I don't have glaucoma at the present moment ?

    Appreicate if someone could share their knowledge.
    Henry, Oct 21, 2003
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  2. (Henry) wrote in
    For a weird reason, I had to see a neuro-ophth about 10 or 12 years ago.
    He was a colleague of mine, and the editor of Neuro-ophthalmology back
    then. He told me I had large cups, and that some time down the road, I
    was bound to be told by an optometrist that glaucoma had to be ruled out.
    He said I shouldn't worry, that I don't have glaucoma, and that I wasn't
    at increased risk for glaucoma. Anatomy works like this sometimes. He
    also handed me my fundus photos on slides, and told me to show these to
    any optometrist who suggested I might have glaucoma.

    I went to a new optometrist about 2 or 3 years ago, and sure enough, he
    started in with the glaucoma thing, and insisted that I take a visual
    field test. I showed him my pictures from a decade before, and that was

    Other profs who have seen my films tell me I have "straight vessels"!

    Scott (not a doctor)
    Scott Seidman, Oct 22, 2003
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  3. Henry

    Henry Guest

    Thanks for responding to my question. I am of east asian origin, were
    you referring to asians when you talked about specific ethnic lines,
    of you were
    talking about people with african ancestry ?
    What is a nerve fiber analysis ? Can this be done in an eye doctor's
    office ? I don't know why my doc never mention this to me. He just
    checked my eye pressure and visual field and said not to worry about
    Henry, Oct 22, 2003
  4. Henry

    Henry Guest

    Scott, Thanks for responding to my question. Can you tell me what a
    fundus photo is ?
    Why would that changed the mind of your new optometrist ?
    Henry, Oct 22, 2003
  5. Henry

    drfrank21 Guest

    You have physiological cupping which is obviously different than
    glaucomatous cupping. Having said that, it's still not unwise to
    run a routine visual field every couple of years to make sure. It's not
    impossible to develop glaucoma with physiological cupping just
    as it's not impossible with someone with low risk factors to
    develop this condition.

    drfrank21, Oct 22, 2003
  6. Henry

    Henry Guest


    Thank you so much for the valuable information provided, it is very helpful.

    Henry, Oct 22, 2003
  7. (drfrank21) wrote in
    Agreed, but does physiological cupping INCREASE the basic risk of
    glaucoma? If not, why should I undergo more than standard IOP
    measurement? It's not impossible for a normal individual to develop
    epilepsy, but you don't send them in for an EEG unless they develop

    Now, if when I showed the fundus photo, the doc said, "I see a change"
    that would be a different story. As well, if my IOP went up, I'd gladly
    sit for the fields.

    Reasons not to sit for the fields: a)time and convenience. b)the risk
    of being categorized as borderline glaucoma might carry insurance
    problems with it down the line as insurance companies get more and more
    access to our records. c) I don't like to think this way, but here it
    is. A field tester is a large, expensive piece of equipment, and it uses
    up resources to support. If an optometrist happens to have one, I think
    that optometrist feels more compelled to use it than if he had to refer
    for the test. What's the current reimbursement for a field test? In
    today's environment, I think as a consumer I should be trying to save my
    insurance company a buck or two when appropriate.

    As a PS, I did have my fields tested by the neuro-ophth as part of the
    standard 3-hour exam.

    Scott Seidman, Oct 22, 2003
  8. (Henry) wrote in
    Fundus photos are a picture of the back of your eye taken by a
    camera/ophthalmoscope combination. Essentially, its generated by the same
    equipment your doctor uses in his exam, but it keeps a permanent record in
    the form of a picture.

    When the optometrist saw the pictures, and didn't notice any major changes
    in his view during the current exam, and heard that a neuroophthalmologist
    (who measured the visual fields) saw the same thing he did and concluded
    that I didn't have glaucoma, and he didn't see any increased IOP, he didn't
    see the need to do the visual fields.

    Scott Seidman, Oct 22, 2003
  9. I keep seeing mentions of pressure not elevated. Please be aware that
    elevated IOP is not required for one to have glaucoma. Glaucoma is a disease
    of the optic nerve, which MAY be associated with elevated IOP, but not
    necessarily. When there is glaucoma with normal pressure, tis is referred to
    as "normal pressure glaucoma", which I believe represents about 10% of the
    glaucoma cases out there.

    One interesting aspect of large physiological cups- if the nrevehead itself
    is larger in diameter than average, the "hole" that the nerve fibers have to
    fill is a larger area than average. Since the number of nerve fibers is
    about constant among normal individuals (about 1.2 million per eye), if the
    area ia larger, the fibers hug the outer diameter of the hole (the nerve
    sheath and entry thru the scleral ring), and therefore will have a central
    unfilled area (the optic nerve cup. Converse is true of a small "crowded"
    nervehead with a tiny physiologic cup. Newer technology is trying to measure
    the area of the nervehead rim to determine loss, rather than going just by
    the cup.

    And yes, after a long time (10-12 yrs in this case) with a large cup, even
    with cups unchanged from the old photos and a normal IOP, I'd still
    recommend a repeat visual field JUST TO MAKE SURE. Can't hoyt.
    (Pun: William Hoyt MD, neuro-ophthalmologist, would probably agree with
    these recommendations.)

    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and strabismus subspecialty
    Member of AAPOS
    (American Academy of Pediatric Ophthalmology and Strabismus)

    David Robins, MD, Oct 23, 2003
  10. Henry

    drfrank21 Guest

    Just a couple of points adding to David's response. First, unless you
    do get serial stereo photos, it can be a little difficult to compare
    you're seeing in real time to the previous photos. Much easier to have
    the stereo photos side by side with a viewer to make the comparison.
    can be subtle differences/changes that can be missed. Secondly, I have
    a FDT
    vf tester in my clinic that will run a threshold n-30 (ie measure to
    30 degrees of field) in about 4 minutes per eye. So the convenience
    is a non-issue unless I need to order additional vf's (30-2) if the
    test was positive. But the exam certainly wouldn't take 3 hours even
    being dilated!

    In your case, there's no need to panic but should be prudent none-of

    drfrank21, Oct 23, 2003
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